Discrimination / Whistleblower Complaint Form



An employee may use this form to file a discrimination complaint if the employee believes the employer has retaliated against the employee for exercising employee rights under the Arizona Occupational Safety and Health Act. Submission of this form constitutes filing a discrimination complaint pursuant to Arizona Revised Statutes (A.R.S.) section 23-425.

It is not necessary to use this form. ADOSH will accept a discrimination complaint made orally (telephone or walk-in) or in writing, and in any language. An employee may also file a complaint or obtain more information by contacting ADOSH Discrimination Investigations at 602-542-5355 or by contacting ADOSH toll free at (855) 268-5251.

This form must include an accurate description of each allegation of retaliation (what happened). The description should include specific evidence supporting the allegation.  IMPORTANT: the information contained in this complaint will be shared with the employer including the complainant’s identity. A whistleblower complaint filed with ADOSH cannot be filed anonymously.

This form can be submitted online by selecting the link below, or it can be submitted to ADOSH by mail, fax, or hand-delivery. ADOSH requires that the complainant sign the complaint allegation.  To access a printer friendly form that you can fill out and mail, fax or hand-deliver to ADOSH, select this link..


Para acceder a la versión en español del formulario de firmar y enviar en línea, seleccione el siguiente enlace

Para acceder a la versión en español del PDF para imprimir, seleccione el siguiente enlace